Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Wednesday, November 21, 2007

I’ve been patting myself on the back so hard the last few days I feel like an auto-erotic respiratory therapist. Here’s the story:

A young guy comes in to our clinic with some complaints of who-knows-the-fuck-what (I’m a pathologist, do you actually think I know the patient’s history? Please.). Anyhoo, he gets a needle biopsy of a retroperitoneal mass they find on a CT scan. The case is assigned to one of our pathologists - a smart and experienced fellow from the old country. He’s not sure what it is and he shows the case around to several other pathologists who are stumped and ultimately the case is sent to an outside, nationally recognized “expert” for an opinion. So, the case is stained-up the wazoo (we have certain markers called immunohistochemical stains that will highlight specific cell types – aiding in classification of tumor type) and shown to everyone on Earth who knows anything about pathology (I’ve told myself one million times: do not exaggerate!). Well, no one has a good idea of what it is but several theories / guesses are floated, “clinical history” is sought from clinicians, conferences ensue and the entire world is wallowing in a morass of self-doubt and hopelessness.

Enter: me.

I was out the day the case came into the department and had not seen the slides. On their return from the “experts”, my colleague brings the case to me and puts a slide under the microscope. I glance briefly at the thinly-cut section stained pink and blue by hematoxalin and eosin. I think for a yoctosecond and declare triumphantly: “Has anyone fondled this guys nuts?”. Blank stares. Slowly, looks of understanding. And then, finally, awe. “It’s a metastatic seminoma. Go check out this guys balls.”

Another mystery solved; another life saved. “Great men are meteors that burn so that the earth may be lighted.” -Napoleon.

Yet another validation that physical examination is a dying art. Medical students these days can't tell an S4 gallop from their sister's tit.

My father recently suffered a massive stroke. Five minutes after I reached his bedside, I knew where it was, how big it was, that it had ruptured into the ventricles and that he wouldn't survive. All by doing an exam. The CT simply confirmed what I already knew.

cholerajoe, you are correct, but i would add this thought. in the ER we too can make snap diagnoses based on exam, clinical intuition, and vital signs etc... only one of my six surgeons will operate based on clinical presentation and exam.

regarding acute neurological emergencies, no one will do anything without a scan.

i'm sorry about your mother, it sounds like the die was cast prior to her arrival at the hospital, but you are correct to note that the physical exam has been killed by technology.

i believe that, if one could get out from under federal mandates and JCAHO requirements that for most patients, we could deliver fine care for much less. it's an idea that i am working on, but one miss and you're sunk.

But, really, why do med students even buy stethoscopes anymore?A couple years ago the CT went down for a whole weekend and we only had 1 at the time. I'm the oldest guy by far in the group, and the young 'uns were in "status" They started ordering MRI's on all the belly's and heads and shit..They were petrified that they had to use clinical judgement and not have a way to objectively reassure themselves..(did get us our own scanner in the dept!)It was kinda funny..CT scans had just been invented when I started this gig and back then you had to get approval from somebody to even order one!!!Maybe I'll go play with my balls now...

yes 911, whitman is correct. and yes, he was wicked gay. As for career choices, pornographer would have been a good one. Either behind the camera or as 'stunt cock'.

I agree with all the sturm und drang about the loss of physical exam skills, although in this case I can't blame the clinicians for being retards (which I love to do) - the nut mass was only seen with ultrasound and was almost completely scarred / regressed. Although I did personally transilluminate his junk just for kicks.

Oldfart. TMI. if, however, you insist on playing with them it is better if you involve a female partner skilled in the arts of testicular stimulation, or a dude, or whatever you choose. you texas guys do a lot of stuff that people don't understand and i'm not judging, haven't judged since the plight of the gay cowboy was so wonderfully portrayed in 'brokeback'. wow, what a movie.

Thanks for the link; always glad to have more links to the Gospel of Shroom ;)EM training in the UK is changing; it used to be a 4 -5 year specialist programme, after any basic training programme (Med., Surg., Anesthetics etc)Now, I think, it's a 2 year "Common" Acute Stem prog, then a 4- 6 year specialist programme... i think.Did that make any sense..?

kinda makes sense. are you meaning 4-6 years from the beginning of medical school to completion OR 4-6 years of residency training after medical school? i know our systems are a bit different. glad to have you on our roll and stop by anytime!

4-6 after med school; so total training to be a consultant (which I guess is the equivalent of an attending) would be about 9 years; for some of us oldies it was longer... we dithered a bit more; I'll be about 12 years in when I'm done.And as for botulism, yes, we really use mice. They used to phone us daily on the unit to advise on the health of the test mice...

I'm still not quite sure how things equivalate UK vs US, but yours sounds shorter...I did 6 years med school, albeit straight out of school, then a year as a house officer (?intern), about 5 years as an SHO (?resident) then anothe 5 as a Registrar (?Senior resident) then... I will be elligible for a consultant post (?attending)... so 6 yers pre grad training, and 11-12 post grad; however i think we work shorter hours. Welll, we for damn sure do now, but even when I was a wee laddie, I'm not sure we ever put in the same number. (Tho my old man, who did some time at the Mayo clinic in the 70s had a few tales to tell about what constituted "busy" for the US knifemen. They in turn laughed at his salary...)

y,y,y I started medschool right out of high school, so at age 18. Even so, That's six years before I qualified, vs your 8, but I still racked up 12 'training' years after graduating. Although, with new training, I'd be doing a comparable no of years. This is not a good thing for the NHS; one estimate is that surgeons of 'yesteryear' did 40,000 HOURS of training, and todays will do 10,000. So your doctor will be young,fresh but inexperienced, as opposed to older, tired and knowing his arse from his elbow... your choice...

I had a post related to the physical exam that doctors may or may not perform. My long winded opinion, such as it is, is posted on my website. I'd be interested in hearing what you all have to say. Especially you Etot.....the creature that secretly makes me wet.......with tears!

If it was metastatic seminoma, it's quite possible the patient won't survive, even with your amazing powers of detection. So I would say it's a little premature to be congratulating yourself on saving a life.